Provider Demographics
NPI:1134626062
Name:BODMER, NICHOLAS PAUL (DO)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:PAUL
Last Name:BODMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 LITCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6600
Mailing Address - Country:US
Mailing Address - Phone:860-496-6666
Mailing Address - Fax:860-496-6633
Practice Address - Street 1:540 LITCHFIELD ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6600
Practice Address - Country:US
Practice Address - Phone:860-496-6666
Practice Address - Fax:860-496-6633
Is Sole Proprietor?:No
Enumeration Date:2018-04-08
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1.069320-DO207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine